Construction of a predictive model for acute liver failure after hepatectomy based on neutrophil-to-lymphocyte ratio and albuminbilirubin score

BACKGROUND Acute liver failure(ALF)is a common cause of postoperative death in patients with hepatocellular carcinoma(HCC)and is a serious threat to patient safety.The neutrophil-to-lymphocyte ratio(NLR)is a common inflammatory indicator that is associated with the prognosis of various diseases,and the albumin-bilirubin score(ALBI)is used to evaluate liver function in liver cancer patients.Therefore,this study aimed to construct a predictive model for postoperative ALF in HCC tumor integrity resection(R0)based on the NLR and ALBI,providing a basis for clinicians to choose appropriate treatment plans.AIM To construct an ALF prediction model after R0 surgery for HCC based on NLR and ALBI.METHODS In total,194 patients with HCC who visited The First People’s Hospital of Lianyungang to receive R0 between May 2018 and May 2023 were enrolled and divided into the ALF and non-ALF groups.We compared differences in the NLR and ALBI between the two groups.The risk factors of ALF after R0 surgery for HCC were screened in the univariate analysis.Independent risk factors were analyzed by multifactorial logistic regression.We then constructed a prediction model of ALF after R0 surgery for HCC.A receiver operating characteristic curve,calibration curve,and decision curve analysis(DCA)were used to evaluate the value of the prediction model.RESULTS Among 194 patients with HCC who met the standard inclusion criteria,46 cases of ALF occurred after R0(23.71%).There were significant differences in the NLR and ALBI between the two groups(P<0.05).The univariate analysis showed that alpha-fetoprotein(AFP)and blood loss volume(BLV)were significantly higher in the ALF group compared with the non-ALF group(P<0.05).The multifactorial analysis showed that NLR,ALBI,AFP,and BLV were independent risk factors for ALF after R0 surgery in HCC.The predictive efficacy of NLR,ALBI,AFP,and BLV in predicting the occurrence of ALT after R0 surgery for HCC was average[area under the curve(AUC)NLR=0.767,AUCALBI=0.755,AUCAFP=0.599,AUCBLV=0.718].The prediction model for ALF after R0 surgery for HCC based on NLR and ALBI had a better predictive efficacy(AUC=0.916).The calibration curve and actual curve were in good agreement.DCA showed a high net gain and that the model was safer compared to the curve in the extreme case over a wide range of thresholds.CONCLUSION The prediction model based on NLR and ALBI can effectively predict the risk of developing ALF after HCC R0 surgery,providing a basis for clinical prevention of developing ALF after HCC R0 surgery.

Development and validation of a new prognostic model for patients with acute-on-chronic liver failure in intensive care unit

BACKGROUND Cirrhotic patients with acute-on-chronic liver failure(ACLF)in the intensive care unit(ICU)have a poor but variable prognoses.Accurate prognosis evaluation can guide the rational management of patients with ACLF.However,existing prognostic scores for ACLF in the ICU environment lack sufficient accuracy.AIM To develop a new prognostic model for patients with ACLF in ICU.METHODS Data from 938 ACLF patients in the Medical Information Mart for Intensive Care(MIMIC)database were used to develop a new prognostic model(MIMIC ACLF)for ACLF.Discrimination,calibration and clinical utility of MIMIC ACLF were assessed by area under receiver operating characteristic curve(AUROC),calibration curve and decision curve analysis(DCA),respectively.MIMIC ACLF was then externally validated in a multiple-center cohort,the Electronic Intensive Care Collaborative Research Database and a single-center cohort from the Second Hospital of Hebei Medical University in China.RESULTS The MIMIC ACLF score was determined using nine variables:ln(age)×2.2+ln(white blood cell count)×0.22-ln(mean arterial pressure)×2.7+respiratory failure×0.6+renal failure×0.51+cerebral failure×0.31+ln(total bilirubin)×0.44+ln(internationalized normal ratio)×0.59+ln(serum potassium)×0.59.In MIMIC cohort,the AUROC(0.81/0.79)for MIMIC ACLF for 28/90-day ACLF mortality were significantly greater than those of Chronic Liver Failure Consortium ACLF(0.76/0.74),Model for End-stage Liver Disease(MELD;0.73/0.71)and MELD-Na(0.72/0.70)(all P<0.001).The consistency between actual and predicted 28/90-day survival rates of patients according to MIMIC ACLF score was excellent and superior to that of existing scores.The net benefit of MIMIC ACLF was greater than that achieved using existing scores within the 50%threshold probability.The superior predictive accuracy and clinical utility of MIMIC ACLF were validated in the external cohorts.CONCLUSION We developed and validated a new prognostic model with satisfactory accuracy for cirrhotic patients with ACLF hospitalized in the ICU.The model-based risk stratification and online calculator might facilitate the rational management of patients with ACLF.

Ultrasound unveiling:Decoding venous congestion in heart failure for precision management of fluid status

This editorial discusses the manuscript by Di Maria et al,published in the recent issue of the World Journal of Cardiology.We here focus on the still elusive pathophysiological mechanisms underlying cardio-renal syndrome(CRS),despite its high prevalence and the substantial worsening of both kidney function and heart failure.While the measure of right atrial pressure through right cardiac catheterization remains the most accurate albeit invasive and costly procedure,integrating bedside ultrasound into diagnostic protocols may substantially enhance the staging of venous congestion and guide therapeutic decisions.In particular,with the assessment of Doppler patterns across multiple venous districts,the Venous Excess Ultrasound(VExUS)score improves the management of fluid overload and provides insight into the underlying factors contributing to cardio-renal interactions.Integrating specific echocardiographic parameters,particularly those concerning the right heart,may thus improve the VExUS score sensitivity,offering perspective into the nuanced comprehension of cardio-renal dynamics.A multidisciplinary approach that consistently incorporates the use of ultrasound is emerging as a promising advance in the understanding and management of CRS.

Successful treatment of acute liver failure due to Wilson’s disease: Serendipity or fortuity?

BACKGROUND Acute liver failure(ALF)may be the first and most dramatic presentation of Wilson’s disease(WD).ALF due to WD(WD-ALF)is difficult to distinguish from other causes of liver disease and is a clear indication for liver transplantation.There is no firm recommendation on specific and supportive medical treatment for this condition.AIM To critically evaluate the diagnostic and therapeutic management of WD-ALF patients in order to improve their survival with native liver.METHODS A retrospective analysis of patients with WD-ALF was conducted in two pediatric liver units from 2018 to 2023.RESULTS During the study period,16 children(9 males)received a diagnosis of WD and 2 of them presented with ALF.The first was successfully treated with an unconventional combination of low doses of D-penicillamine and zinc plus steroids,and survived without liver transplant.The second,exclusively treated with supportive therapy,needed a hepatotransplant to overcome ALF.CONCLUSION Successful treatment of 1 WD-ALF patient with low-dose D-penicillamine and zinc plus steroids may provide new perspectives for management of this condition,which is currently only treated with liver transplantation.

Comprehensive effects of traditional Chinese medicine treatment on heart failure and changes in B-type natriuretic peptide levels: A meta-analysis

BACKGROUND Heart failure(HF),a common cardiovascular condition,is characterized by significant morbidity and mortality.While traditional Chinese medicine(TCM)is often used as a complementary approach in HF management,systematic evalua-tions of its impact on clinical outcomes,TCM syndrome scores,and B-type natriuretic peptide(BNP)levels are lacking.This study fills this gap through a comprehensive analysis of randomized controlled trials(RCTs)focusing on TCM for HF treatment.It encompasses an assessment of methodological quality,a meta-analysis,and an evaluation of evidence quality based on established standards.The results offer crucial insights into the potential advantages and constraints of TCM in HF management.RCTs on TCM for HF treatment published since the establishment of the database were searched in four Chinese and English databases,including China National Knowledge Infrastructure,Wanfang,VIP Information Chinese Science and Technology Journal,and PubMed.Methodological quality was assessed for the included studies with the Cochrane risk-of-bias assessment tool,and the meta-analysis and publication bias assessment was performed with the RevMan5.3 software.Finally,the quality of evidence was rated according to the GRADE criteria.RESULTS A total of 1098 RCTs were initially retrieved.After screening,16 RCTs were finally included in our study,which were published between 2020 and 2023.These RCTs involved 1660 HF patients,including 832 in the TCM group[TCM combined with conventional Western medicine(CMW)treatment]and 828 in the CWM group(CWM treatment).The course of treatments varied from 1 wk to 3 months.TCM syndrome differentiation was analyzed in 11 of the included RCTs.In all included RCTs,outcome indicators included comprehensive clinical outcomes,TCM syndrome scores,and BNP levels.The meta-analysis results showed significant differences between the TCM and CWM groups in terms of comprehensive clinical outcomes[risk ratio=-0.54;95%confidence interval(CI)=-0.61,-0.47;P<0.00001],TCM syndrome scores[weighted mean difference(WMD)=-142.07;95%CI=-147.56,-136.57;P<0.00001],and BNP levels(WMD=-142.07;95%CI=-147.56,-136.57;P<0.00001).According to the GRADE criteria,RCTs where"TCM improves clinical comprehensive outcomes"were rated as low-quality evidence,and RCTs where"TCM reduces TCM syndrome scores"or"TCM decreases BNP levels"were rated as medium-quality evidence.CONCLUSION TCM combined with CWM treatment effectively improves comprehensive clinical outcomes and diminishes TCM syndrome scores and BNP levels in HF patients.Given the low and medium quality of the included RCTs,the application of these results should be cautious.

Lymphocyte-to-white blood cell ratio is associated with outcome in patients with hepatitis B virus-related acute-on-chronic liver failure

BACKGROUND The lymphocyte-to-white blood cell ratio(LWR)is a blood marker of the systemic inflammatory response.The prognostic value of LWR in patients with hepatitis B virus-associated acute-on-chronic liver failure(HBV-ACLF)remains unclear.AIM To explore whether LWR could stratify the risk of poor outcomes in HBV-ACLF patients.METHODS This study was conducted by recruiting 330 patients with HBV-ACLF at the Department of Gastroenterology in a large tertiary hospital.Patients were divided into survivor and non-survivor groups according to their 28-d prognosis.The independent risk factors for 28-d mortality were calculated by univariate and multivariate Cox regression analyses.Patients were divided into low-and high-LWR groups according to the cutoff values.Kaplan-Meier analysis was performed according to the level of LWR.RESULTS During the 28-d follow-up time,135 patients died,and the mortality rate was 40.90%.The LWR level in non-surviving patients was significantly decreased compared to that in surviving patients.A lower LWR level was an independent risk factor for poor 28-d outcomes(hazard ratio=0.052,95%confidence interval:0.005-0.535).The LWR level was significantly negatively correlated with the Child-Turcotte-Pugh,model for end-stage liver disease,and Chinese Group on the Study of Severe Hepatitis B-ACLF II scores.In addition,the 28-d mortality was higher for patients with LWR<0.11 than for those with LWR≥0.11.CONCLUSION LWR may serve as a simple and useful tool for stratifying the risk of poor 28-d outcomes in HBVACLF patients.

24h乳酸清除率和序贯器官衰竭评分及简化急性生理评分Ⅱ对脓毒症预后的预测价值研究

目的探究简化急性生理评分Ⅱ(simplified acute physiological score-Ⅱ,SAPSⅡ)、序贯器官衰竭评估(sequential organ failure assessment,SOFA)评分及24 h乳酸清除率(24 h lactate clearance,LCR)对脓毒症患者预后的预测价值。方法回顾性研究,选取2023年1月—2024年1月郑州大学第一附属医院外科ICU诊治的96例脓毒症患者,依据预后情况将患者分为生存组71例及死亡组25例。比较两组患者实验室指标[血钙、降钙素原(procalcitonin,PCT)、乳酸脱氢酶(lactate dehydrogenase,LDH)]等水平,24 h LCR、SAPSⅡ评分及SOFA评分,logistic分析24 h LCR、SOFA评分及SAPSⅡ评分对患者预后独立危险因素,ROC曲线评估24 h LCR、SOFA评分及SAPSⅡ评分对患者预后的预测价值。结果生存组血钙指标(2.03±0.21)mmol/L高于死亡组(1.65±0.12)mmol/L,PCT、LDH指标分别是(3.25±0.16)μg/L及(4.93±1.26)mmol/L,均低于死亡组,差异有统计学意义(P<0.05);生存组24 h LCR(30.21±6.73)%高于死亡组(22.16±5.92)%,SAPSⅡ评分及SOFA评分分别是(37.29±7.15)分和(5.86±1.47)分,均低于死亡组,差异有统计学意义(P<0.05);logistic分析数据表明,24 h LCR、SOFA评分及SAPSⅡ评分是患者预后独立危险因素,(P<0.05);ROC曲线分析结果表明:24 h LCR预测患者预后曲线下面积为0.753,灵敏度为74.2%、特异度为73.4%;SOFA评分预测患者预后曲线下面积为0.775,灵敏度为82.9%、特异度为74.8%;SAPSⅡ评分预测患者预后曲线下面积为0.772,灵敏度为85.6%、特异度为72.5%;三者联合预测患者预后曲线下面积为0.802,灵敏度为86.4%、特异度为81.9%。结论SOFA及SAPSⅡ评分、24 h LCR联合血钙、PCT对患者预后有较高预测价值,可作为患者预后的预测指标。

基于NSGA-Ⅱ的复合材料防撞梁碰撞损伤多目标优化

为在设计时考虑低速碰撞损伤对碳纤维复合材料(CFRP)防撞梁力学性能的影响,发展了改进Hashin失效准则的VUSDFLD子程序来判定低速碰撞时CFRP防撞梁7个方向的损伤程度,采用壳单元模拟了复合材料的力学性能,建立了CFRP防撞梁低速碰撞有限元显式动力学模型。采用该方法对相同实验条件下的复合材料层合板低速冲击剩余强度进行了计算,并将计算结果与实验结果进行了对比,仿真结果与实验结果吻合较好。在此基础上,以复合材料防撞梁铺层厚度和铺层角度为设计变量,将复合材料防撞梁的质量和低速冲击时产生的损伤单元数作为优化目标,建立了CFRP防撞梁低速碰撞损伤动力学多目标优化模型,采用基于Pareto策略改进的NSGA-Ⅱ非支配排序遗传算法对其进行多目标优化求解。优化后,CFRP防撞梁质量由1.02 kg降为0.76 kg,减重率为25%;损伤单元数由30238个降为23206个,损伤降低率为23%。结果表明,所发展基于Hashin失效准则的VUSDFLD子程序和对CFRP防撞梁低速碰撞损伤多目标优化是行之有效的,为复合材料防撞梁结构的优化设计提供了参考。

Validation of a surgical model for posthepatectomy liver failure in rats

Background:The upper limit for liver resections in rats is approximately 90%.In the early postoperative phase,mortality increases.The aim of the present study was to validate the rat model of 90%partial hepatectomy(PH)as a model of post-hepatectomy liver failure(PHLF).Further,we wanted to test a quantitative scoring system as a detector of lethal outcomes caused by PHLF in rats.Methods:Sixty-eight rats were randomized to 90%PH,sham operation,or no sur-gery.Further,block randomization was performed based on time of euthanization:12,24,or 48 h after surgery.A general distress score(GDS)≥10 during the day or≥6 at midnight prompted early euthanization and classification as nonsurvivor.Animals euthanized as planned were classified as survivors.During euthanization,blood and liver tissue were collected,and liver-specific biochemistry was evaluated.Results:Based on the biochemical results,all animals subjected to 90%PH expe-rienced PHLF.Seventeen rats were euthanized due to irreversible PHLF.The GDS increased for nonsurvivors within 12–18 h after surgery.The mean time for euthaniza-tion was 27 h after surgery.Conclusion:Based on the GDS and liver-specific biochemistry,we concluded that the model of 90%PH seems to be a proper model for investigating PHLF in rats.As a high GDS is associated with increased mortality,the GDS appears to be valuable in detect-ing lethal outcomes caused by PHLF in rats.

Acute-on-chronic liver failure is independently associated with higher mortality for cirrhotic patients with acute esophageal variceal hemorrhage:Retrospective cohort study

BACKGROUND Acute esophageal variceal hemorrhage(AEVH)is a common complication of cirrhosis and might precipitate multi-organ failure,causing acute-on-chronic liver failure(ACLF).AIM To analyze if the presence and grading of ACLF as defined by European Society for the Study of the Liver-Chronic Liver Failure(EASL-CLIF)is able to predict mortality in cirrhotic patients presenting AEVH.METHODS Retrospective cohort study executed in Hospital Geral de Caxias do Sul.Data from medical records from 2010 to 2016 were obtained by searching the hospital electronic database for patients who received terlipressin.Medical records were reviewed in order to determine the diagnosis of cirrhosis and AEVH,including 97 patients.Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis.RESULTS All-cause mortality for AEVH patients was 36%,40.2%and 49.4%for 30-,90-and 365-day,respectively.The prevalence of ACLF was 41.3%.Of these,35%grade 1,50%grade 2 and 15%grade 3.In multivariate analysis,the non-use of non-selective beta-blockers,presence and higher grading of ACLF and higher Model for End-Stage Liver Disease scores were independently associated with higher mortality for 30-day with the addition of higher Child-Pugh scores for 90-day period.CONCLUSION Presence and grading of ACLF according to the EASL-CLIF criteria was independently associated with higher 30-and 90-day mortality in cirrhotic patients admitted due to AEVH.

Score model for predicting acute-on-chronic liver failure risk in chronic hepatitis B

AIM: To establish a clinical scoring model to predict risk of acute-on-chronic liver failure(ACLF) in chronic hepatitis B(CHB) patients.METHODS: This was a retrospective study of 1457 patients hospitalized for CHB between October 2008 and October 2013 at the Beijing Ditan Hospital, Capital Medical University, China. The patients were divided into two groups: severe acute exacerbation(SAE) group(n = 382) and non-SAE group(n = 1075). The SAE group was classified as the high-risk group based on the higher incidence of ACLF in this group than in the non-SAE group(13.6% vs 0.4%). Two-thirds of SAE patients were randomly assigned to risk-model derivation and the other one-third to model validation. Univariate risk factors associated with the outcome were entered into a multivariate logistic regression model for screening independent risk factors. Each variable was assigned an integer value based on the regression coefficients, and the final score was the sum of these values in the derivation set. Model discrimination and calibration were assessed using area under the receiver operating characteristic curve and the Hosmer-Lemeshow test. RESULTS: The risk prediction scoring model includedthe following four factors: age ≥ 40 years, total bilirubin ≥ 171 μmol/L, prothrombin activity 40%-60%, and hepatitis B virus DNA > 107 copies/m L. The sum risk score ranged from 0 to 7; 0-3 identified patients with lower risk of ACLF, whereas 4-7 identified patients with higher risk. The Kaplan-Meier analysis showed the cumulative risk for ACLF and ACLF-related death in the two risk groups(0-3 and 4-7 scores) of the primary cohort over 56 d, and log-rank test revealed a significant difference(2.0% vs 33.8% and 0.8% vs 9.4%, respectively; both P < 0.0001). In the derivation and validation data sets, the model had good discrimination(C index = 0.857, 95% confidence interval: 0.800-0.913 and C index = 0.889, 95% confidence interval: 0.820-0.957, respectively) and calibration demonstrated by the Hosmer-Lemeshow test(χ2 = 4.516, P = 0.808 and χ2 = 1.959, P = 0.923, respectively).CONCLUSION: Using the scoring model, clinicians can easily identify patients(total score ≥ 4) at high risk of ACLF and ACLF-related death early during SAE.

Predicting mortality in patients with acute heart failure:Role of risk scores

Acute heart failure is a leading cause of hospitalization and death,and it is an increasing burden on health care systems. The correct risk stratification of patients could improve clinical outcome and resources allocation,avoiding the overtreatment of low-risk subjects or the early,inappropriate discharge of high-risk patients. Many clinical scores have been derived and validated for in-hospital and post-discharge survival; predictive models include demographic,clinical,hemodynamic and laboratory variables. Data sets are derived from public registries,clinical trials,and retrospective data. Most models show a good capacity to discriminate patients who reach major clinical end-points,with C-indices generally higher than 0.70,but their applicability in realworld populations has been seldom evaluated. No study has evaluated if the use of risk score-based stratification might improve patient outcome. Some variables(age,blood pressure,sodium concentration,renal function) recur in most scores and should always be considered when evaluating the risk of an individual patient hospitalized for acute heart failure. Future studies will evaluate the emerging role of plasma biomarkers.

Progress in hepatitis B virus-related acute-on-chronic liver failure treatment in China:A large,multicenter,retrospective cohort study using a propensity score matching analysis

Background:Hepatitis B virus-related acute-on-chronic liver failure(HBV-ACLF)has a high short-term mortality.However,the treatment progression for HBV-ACLF in China in the past decade has not been well characterized.The present study aimed to determine whether the HBV-ACLF treatment has significantly improved during the past decade.Methods:This study retrospectively compared short-term(28/56 days)survival rates of two different nationwide cohorts(cohort I:2008-2011 and cohort II:2012-2015).Eligible HBV-ACLF patients were enrolled retrospectively.Patients in the cohorts I and II were assigned either to the standard medical therapy(SMT)group(cohort I-SMT,cohort II-SMT)or artificial liver support system(ALSS)group(cohort IALSS,cohort II-ALSS).Propensity score matching analysis was conducted to eliminate baseline differences,and multivariate logistic regression analysis was used to explore the independent factors for 28-day survival.Results:Short-term(28/56 days)survival rates were significantly higher in the ALSS group than those in the SMT group(P<0.05)and were higher in the cohort II than those in the cohort I(P<0.001).After propensity score matching,short-term(28/56 days)survival rates were higher in the cohort II than those in the cohort I for both SMT(60.7%vs.53.0%,50.0%vs.39.8%,P<0.05)and ALSS(66.1%vs.56.5%,53.0%vs.44.4%,P<0.05)treatments.The 28-day survival rate was higher in patients treated with nucleos(t)ide analogs than in patients without such treatments(P=0.046).Multivariate logistic regression analysis revealed that ALSS(OR=0.962,95%CI:0.951-0.973,P=0.038),nucleos(t)ide analogs(OR=0.927,95%CI:0.871-0.983,P=0.046),old age(OR=1.028,95%CI:1.015-1.041,P<0.001),total bilirubin(OR=1.002,95%CI:1.001-1.003,P=0.004),INR(OR=1.569,95%CI:1.044-2.358,P<0.001),COSSH-ACLF grade(OR=2.683,95%CI:1.792-4.017,P<0.001),and albumin(OR=0.952,95%CI:0.924-0.982,P=0.002)were independent factors for 28-day mortality.Conclusions:The treatment for patients with HBV-ACLF has improved in the past decade.

Sequential organ failure assessment score is superior to other prognostic indices in acute pancreatitis

BACKGROUND Acute pancreatitis(AP)is a common surgical condition,with severe AP(SAP)potentially lethal.Many prognostic indices,including;acute physiology and chronic health evaluation II score(APACHE II),bedside index of severity in acute pancreatitis(BISAP),Glasgow score,harmless acute pancreatitis score(HAPS),Ranson’s score,and sequential organ failure assessment(SOFA)evaluate AP severity and predict mortality.AIM To evaluate these indices'utility in predicting severity,intensive care unit(ICU)admission,and mortality.METHODS A retrospective analysis of 653 patients with AP from July 2009 to September 2016 was performed.The demographic,clinical profile,and patient outcomes were collected.SAP was defined as per the revised Atlanta classification.Values for APACHE II score,BISAP,HAPS,and SOFA within 24 h of admission were retrospectively obtained based on laboratory results and patient evaluation recorded on a secure hospital-based online electronic platform.Data with<10%missing data was imputed via mean substitution.Other patient information such as demographics,disease etiology,and patient outcomes were also derived from electronic medical records.RESULTS The mean age was 58.7±17.5 years,with 58.7%males.Gallstones(n=404,61.9%),alcohol(n=38,5.8%),and hypertriglyceridemia(n=19,2.9%)were more common aetiologies.81(12.4%)patients developed SAP,20(3.1%)required ICU admission,and 12(1.8%)deaths were attributed to SAP.Ranson’s score and APACHE-II demonstrated the highest sensitivity in predicting SAP(92.6%,80.2%respectively),ICU admission(100%),and mortality(100%).While SOFA and BISAP demonstrated lowest sensitivity in predicting SAP(13.6%,24.7%respectively),ICU admission(40.0%,25.0%respectively)and mortality(50.0%,25.5%respectively).However,SOFA demonstrated the highest specificity in predicting SAP(99.7%),ICU admission(99.2%),and mortality(98.9%).SOFA demonstrated the highest positive predictive value,positive likelihood ratio,diagnostic odds ratio,and overall accuracy in predicting SAP,ICU admission,and mortality.SOFA and Ranson’s score demonstrated the highest area under receiver-operator curves at 48 h in predicting SAP(0.966,0.857 respectively),ICU admission(0.943,0.946 respectively),and mortality(0.968,0.917 respectively).CONCLUSION The SOFA and 48-h Ranson’s scores accurately predict severity,ICU admission,and mortality in AP,with more favorable statistics for the SOFA score.

A Novel Prognostic Score for Acute-on-Chronic Hepatitis B Liver Failure

Patients with acute-on-chronic hepatitis B liver failure（HBV-ACLF） show high morbidity and mortality. Independent prognostic predictors of short-term HBV-ACLF mortality include the Child-Turcotte-Pugh（CTP） score, the model for end-stage liver disease（MELD） score, other MELD-based indices and the dynamic changes in these indices. The aims of this study were to evaluate the existing prognostic scores in a large cohort of HBV-ACLF patients and create a new predictive model. We retrospectively reviewed 392 HBV-ACLF patients from December 2008 to November 2011 and evaluated their 3-month survival. The predictive accuracy of CTP, MELD and MELD-based indices and the dynamic changes in the MELD-related scores（Δ scoring systems） upon admission and after two weeks of treatment were compared using the area under the receiver operating characteristic（ROC） curve method. Life-threatening factors and a series of bio-clinical parameters were studied by univariate and multivariate analyses. Among the existing scores, MELD had the best predictive ability. However, our new regression model provided an area under the curve of 0.930±0.0161（95% CI： 0.869 to 0.943）, which was significantly larger than that obtained with the MELD score at admission and after two weeks of treatment as well as with the dynamic changes of the MELD score（0.819, 0.921, and 0.826, respectively）（Z=3.542, P=0.0004）. In a large cohort of patients retrospectively reviewed for this study, our prognostic model was superior to the MELD score and is, therefore, a promising predictor of short-term survival in patients with HBV-ACLF.

Construction of Parsimonious Event Risk Scores by an Ensemble Method. An Illustration for Short-Term Predictions in Chronic Heart Failure Patients from the GISSI-HF Trial

Selecting which explanatory variables to include in a given score is a common difficulty, as a balance must be found between statistical fit and practical application. This article presents a methodology for constructing parsimonious event risk scores combining a stepwise selection of variables with ensemble scores obtained by aggregation of several scores, using several classifiers, bootstrap samples and various modalities of random selection of variables. Selection methods based on a probabilistic model can be used to achieve a stepwise selection for a given classifier such as logistic regression, but not directly for an ensemble classifier constructed by aggregation of several classifiers. Three selection methods are proposed in this framework, two involving a backward selection of the variables based on their coefficients in an ensemble score and the third involving a forward selection of the variables maximizing the AUC. The stepwise selection allows constructing a succession of scores, with the practitioner able to choose which score best fits his needs. These three methods are compared in an application to construct parsimonious short-term event risk scores in chronic HF patients, using as event the composite endpoint of death or hospitalization for worsening HF within 180 days of a visit. Focusing on the fastest method, four scores are constructed, yielding out-of-bag AUCs ranging from 0.81 (26 variables) to 0.76 (2 variables).

Development of a novel score for the diagnosis of bacterial infection in patients with acute-on-chronic liver failure

BACKGROUND The diagnosis of bacterial infection is difficult in patients with acute-on-chronic liver failure(ACLF).AIM To evaluate the diagnostic accuracy of widely used parameters for bacterial infection in ACLF and to develop a simple scoring system to improve diagnostic efficiency.METHODS This was a retrospective study.Procalcitonin(PCT),white blood cells(WBC),proportion of neutrophils(N%),and C-reactive protein(CRP)were examined.Logistic regression was used to select variables for the scoring models and receiver operating characteristic curve(ROC)analysis was used to evaluate the diagnostic value of different indices.RESULTS This study included 386 patients with ACLF,169(43.78%)of whom had bacterial infection on admission.The area under the ROC(AUROC)of PCT,CRP,WBC and N%for the diagnosis of bacterial infection ranged from 0.637 to 0.692,with no significant difference between them.Logistic regression showed that only N%,PCT,and CRP could independently predict infection.A novel scoring system(infection score)comprised of N%,PCT and CRP was developed.The AUROC of the infection score was 0.740,which was significantly higher than that for the other four indices(infection score vs N%,PCT,CRP,and WBC,P=0.0056,0.0001,0.0483 and 0.0008,respectively).The best cutoff point for the infection score was 4 points,with a sensitivity of 78.05%,a specificity of 55.29%,a positive predictive value of 57.91%and a negative predictive value of 76.16%.CONCLUSION The infection score is a simple and useful tool for discriminating bacterial infection in ACLF.

经鼻高流量湿化氧疗联合莫西沙星溶液雾化吸入在慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭中的疗效观察

目的探讨经鼻高流量湿化氧疗(HFNC)联合莫西沙星溶液雾化吸入在慢性阻塞性肺疾病(COPD)合并Ⅱ型呼吸衰竭中的疗效。方法纳入86例慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭患者,分为对照组(n=43)、观察组(n=43)。对照组予以经鼻高流量湿化氧疗治疗,观察组予以经鼻高流量湿化氧疗联合莫西沙星溶液雾化吸入治疗,比较2组患者治疗前后的6 min步行距离(6 MWD),改良医学研究学会呼吸困难量表(MMRC)、慢性阻塞性肺疾病评估量表(CAT)评分,动脉血氧分压(PaO_(2))、动脉血二氧化碳分压(PaCO_(2))、血浆内皮素-1(EF-1)、组织金属蛋白酶抑制剂-1(TIMP-1)、基质金属蛋白酶-9(MMP-9)、第1 s用力呼气容积(FEV_(1))、第1 s用力呼气容积与用力肺活量的比值(FEV_(1)/FVC)、丙二醛(MDA)、超氧化物歧化酶(SOD)的水平。结果观察组治疗后6 MWD较对照组长(P<0.05),MMRC评分、CAT评分较对照组低(P<0.05);观察组PaO_(2)、FEV_(1)、FEV_(1)/FVC、SOD水平较对照组高(P<0.05);观察组PaCO_(2)、EF-1、TIMP-1、MMP-9、MDA水平较对照组低(P<0.05)。结论经鼻高流量湿化氧疗联合莫西沙星溶液雾化吸入在慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭患者中的应用可以显著提高患者的运动能力、呼吸功能、生活质量、血气指标和肺功能,同时减少炎症反应和氧化应激。

Weighing of risk factors for penetrating keratoplasty graft failure：application of Risk Score System

AIM：To analyze the relationship between the score obtained in the Risk Score System（RSS）proposed by Hicks et al with penetrating keratoplasty（PKP）graft failure at 1y postoperatively and among each factor in the RSS with the risk of PKP graft failure using univariate and multivariate analysis.METHODS：The retrospective cohort study had 152 PKPs from 152 patients. Eighteen cases were excluded from our study due to primary failure（10 cases）,incomplete medical notes（5 cases）and follow-up less than 1y（3cases）. We included 134 PKPs from 134 patients stratified by preoperative risk score. Spearman coefficient was calculated for the relationship between the score obtained and risk of failure at 1y. Univariate and multivariate analysis were calculated for the impact of every single risk factor included in the RSS over graft failure at 1y. RESULTS：Spearman coefficient showed statistically significant correlation between the score in the RSS and graft failure（P〈0.05）. Multivariate logistic regression analysis showed no statistically significant relationship（P〉0.05）between diagnosis and lens status with graft failure. The relationship between the other risk factors studied and graft failure was significant（P〈0.05）,although the results for previous grafts and graft failure was unreliable. None of our patients had previous blood transfusion,thus,it had no impact. CONCLUSION：After the application of multivariate analysis techniques,some risk factors do not show the expected impact over graft failure at 1y.

基于急性生理与慢性健康状况评分系统Ⅱ的预见性干预模式在重症脓毒症患者治疗中的应用

目的:探讨急性生理与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分的预见性干预模式对重症脓毒症患者治疗指标的影响.方法:选取2022年1月至2023年5月本院收治的92例重症脓毒症患者作为研究对象.依据干预模式,将其分为研究组(n=46,给予基于APACHEⅡ评分的预见性干预)和对照组(n=46,给予常规干预).比较两组患者各项治疗指标.结果:研究组患者机械通气时间、抗菌药物使用时间、ICU住院时间短于对照组,住院费用比低于对照组,差异均有统计学意义(P<0.05);研究组患者干预6h后,中心静脉压、平均动脉压、中心静脉血氧浓度(ScvO_(2))、动脉血氧分压(PaO_(2))、PaO_(2)与吸入氧分数(FiO_(2))的比率(PaO_(2)/FiO_(2))值高于对照组,心率均低于对照组,差异均有统计学意义(P<0.05);两组患者并发症发生率比较,差异无统计学意义(P>0.05).结论:基于APACHEⅡ评分的预见性干预模式可有效改善重症脓毒症患者的相关治疗指标,值得临床推广.